Heart Failure

Abstract

The prevalence of heart failure in women is increasing. Heart failure is as common in women as it is in men. However, the prevalence in women is lower in the younger age groups (under 70–75 years of age) and higher in women over 75 years compared to men. The clinical diagnosis of heart failure has a lower validity and is less precise in women compared to men. This emphasizes the need for verification of the diagnosis with echocardiography, especially in women. The etiology of heart failure is more often nonischemic in women, and particularly hypertension and valve disease are more common causes in women than in men. In general, survival is better in women than in men. This may be due to the more common nonischemic etiology and the better preserved left ventricular function, as seen in hypertension and valve disease, together with a difference in the aging process in women compared to men. In heart failure due to ischemic heart disease, mortality seems to be the same for women and men. The effect of the established medical treatment on mortality and morbidity is less well established in women compared to men. This may be explained by the low percentage of women included in the available randomized studies (often only 20–25%). The low number of women in the randomized trials may be explained by the age criteria, including only relatively younger patients, and consequently they do not truly represent the population of women with heart failure. It may also be due to the fact that most heart failure studies include only patients with systolic left ventricle dysfunction, and female patients are not included because they have a higher prevalence of heart failure with preserved heart function. In general, the effect of β-blockers seems to be the same in women and men. There was a tendency for a smaller effect of ACE inhibitor treatment, whereas the effect was the same for angiotensin II receptor blocker (ARB) treatment. Spironolactone and eplerenone showed the same effect in women and men. In contrast, digoxin had no effect and may even worsen the prognosis in women. Treatment with devices, implantable cardiac defibrillator (ICD) units, and cardiac resynchronization therapy (CRT) should be given for the same indications in women as in men and, according to the recent RAFT study, should even be considered in patients with milder symptoms. Treatment of heart failure in women should follow the general recommendations based on randomized trials and include diuretics in case of fluid retention, ACE inhibitors or ARB and β-blockers in case of reduced systolic pump function under 40%, and spironolactone in case of continued symptoms and reduced left ventricular function. Finally device implantation with an ICD unit and or CRT should be considered in patients with symptoms despite medical treatment and ejection fractions (EF) <35%. Prophylactic combined CRT and ICD in patients without or with only mild symptoms and EF <30% is not yet standard treatment, but based on the most recent trials this may be considered in the future. In order to elucidate gender differences in treatment effect, future trials should aim to include more women.